VBS 2022 Form

- MAKE WAVES - Astoria Citywide VBS 2022 Registration Form

June 20-24, 2022, 9:00 am to Noon, Peace First Lutheran downtown campus, corner of 12th & Exchange. Ages 3 through 5th grade. Last day to register online is June 17th. No on-site registration. COST: The cost is $15 for one student or $25 per family. Fees will be paid upon check-in the first day. (No child will be turned away for lack of funds). Please fill out individual registration forms for each participating child. Items marked with a * are required fields.
Student Name *

First Name Last Name
Birth Date *

Month Day Year
Gender *
Student's age *
Physical Address *

Street Address (No PO BOX please)

Street Address Line 2

City State

Zip Code
Please let us know of any food allergies or health conditions:
Which days will the student be able to attend? *

Monday Tuesday Wednesday Thursday Friday
Name of church you attend, if any: *
(if no church affiliation type "None")
Would you be interested in a city-wide Youth Group?

YES NO
Parent / Guardian Name *

First Name Last Name
Parent / Guardian Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian E-mail
example@example.com
Phone Number *
Emergency contact name & relation
Emergency Number
Are you able to volunteer to help?

YES NO
If yes, what days can you help out?

Monday Tuesday Wednesday Thursday Friday
Medical Release Statement:

In cast of a medical emergency, I Understand every reasonable effort will be made to contact me. In the event that I cannot be reached through reasonable efforts, I heareby give my permission to the physician selected by the program director to secure proper treatment or to hospitalize, to order injections, anesthesia, or surgery for my child. On behalf of the parents/guardians, I further agree that I will not hold the sponsoring churches of the Astoria Central City VBS, their agents or employees, responsible for any accident or injury.
Medical Release Statement agreed to? *

YES NO
Pediatrician's name *
Pediatrician's phone *
Please enter a valid phone number.
Photographs:

We take photgraphs throughout the VBS week to put on our website. In addition, we produce a brochure for the parents to see the various activities that their child has participated in and to promote next year's VBS.
Permission to publish your child's photograph? *

YES NO
Additional Comments
Signature *

Clear
Should be Empty:

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- MAKE WAVES - Astoria Citywide VBS 2022 Registration Form